A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?

Command hallucinations.

Impaired memory.

Inappropriate speech patterns.

Rapid mood swings.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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Correct Answer is C

Explanation

Choice A rationale:

Illness anxiety disorder. Illness anxiety disorder, formerly known as hypochondriasis, is characterized by excessive worry about having a serious illness despite having no or mild medical symptoms. This disorder primarily involves excessive health-related anxiety and preoccupation with the idea of having a severe illness. It is not associated with physical symptoms causing distress and impairment in daily life, as described in the question.

Choice B rationale:

Conversion disorder. Conversion disorder, also known as functional neurological symptom disorder, is characterized by the presence of neurological symptoms that cannot be explained by a medical condition. These symptoms are not intentionally produced and often involve motor or sensory deficits. In this disorder, there is a disconnection between psychological distress and physical symptoms, but it does not involve chronic physical symptoms or the intentional production of symptoms, as mentioned in the question.

Choice D rationale:

Factitious disorder. Factitious disorder involves intentional production of physical or psychological symptoms to assume the role of a sick person. People with this disorder often seek medical attention, and they may even harm themselves to create symptoms. However, factitious disorder does not fully explain the chronic physical symptoms that the client in the question is experiencing. This disorder is more about the intentional creation of symptoms rather than distress from chronic physical symptoms. Now, let's move on to the next question.

A. Alcohol. B. Heroin. C. Opium. D. Cocaine.

Correct Answer is D

Explanation

Choice A rationale:

Alcohol toxicity typically presents with symptoms such as confusion, slurred speech, and ataxia, rather than paranoia ("People are out to get me"). While alcohol can cause increased heart rate and blood pressure, it is not the most likely substance to cause these symptoms in the context of paranoia.

Choice B rationale:

Heroin toxicity is characterized by central nervous system depression, pinpoint pupils, and respiratory depression, which do not align with the client's symptoms of paranoia, tachycardia, and hypertension.

Choice C rationale:

Opium toxicity shares some similarities with heroin toxicity, including central nervous system depression and pinpoint pupils. It is not typically associated with paranoia or the vital sign changes described in the scenario.

Choice D rationale:

Cocaine toxicity is the most likely cause of the client's symptoms. Cocaine can lead to paranoia, tachycardia, and hypertension. The combination of these symptoms suggests acute cocaine toxicity, making it the priority concern for the nurse. Prompt intervention is necessary to address the potential life-threatening effects of cocaine toxicity.

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A nurse is assessing a client who has delirium.Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who exhibits chronic physical symptoms that cannot be fully explained by medical conditions.These symptoms cause distress and impairment in the client's daily life.What term is used to describe this condition?

Correct Answer is C

Explanation

A nurse is assessing a client who has a history of substance use disorder and states, "People are out to get me.”. The client has tachycardia and hypertension.The nurse should suspect acute toxicity of which of the following substances?

Correct Answer is D

Explanation

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A nurse is assessing a client who has delirium.
Which of the following findings requires immediate intervention by the nurse?